Ninth Meeting of the Sub- group on PPM for TB Care and Control and Global Workshop on Engaging Large Hospitals, 28-30 August 2013 Country experience on engaging large hospitals - INDIA Sreenivas A Nair WHO Country Office for India 1
Will discuss: The Challenge WHO-RNTCP TB PPM model- Involving Medical Colleges Formation Structure Monitoring Results Success factors, challenges and opportunities 2
Tuberculosis in India and scope of PPM Other countries 18% India 25% Phillipines 3% Other 13 HBCs 18% Pakistan 5% Ethiopia 3% Bangladesh 4% Nigeria South Africa 2% 6% Indonesia 5% China 11% TB notification in India 2012 2.2 (2-2.5) 1.3 Missing nearly a million incident cases!
Medical Colleges: Need for involvement Medical college faculty Opinion leaders and trendsetters Teachers imparting knowledge & skills Role models for practicing physicians Large hospitals Out patient care In patient care- specialty services
Involvement of medical colleges: milestones 1997: National consensus conference on TB Control 2001: National workshop of medical college professors 2002: Consensus workshops in states, medical colleges, Identification of seven nodal centers and Evolution of task force mechanism, processes & structure 2003: Annual national and zonal task force meetings State Task force meetings Operational research committees.
Structure of Task forces National Task Force CTD 7 Medical Colleges NTI NIRT NITRD WHO STO of each State Zonal Task Force State Task Force representative from each State (Med Col) State Task Force - 2 tier in States with large number of Med Col STO of the state Representative 1 from each Medical College
Steps for medical college involvement Form core committee Sensitization of faculty members Identify and train staff Appoint and train contractual staff as required and sanctioned (MO/ LT/ TBHV) Establish a DMC cum DOT centre
Roles and responsibilities RNTCP provides support for: Commodity Assistance Drugs Lab consumables Printed material Binocular microscopes Manpower support Contractual staff Training of staff Civil works for laboratory, PMDT site Expectations from medical colleges Diagnosis and treatment of TB including DR-TB For outdoor patients For indoor cases Reporting requirements Monthly program management report to RNTCP Quarterly report to State Task Force PMDT reports
Patients from RNTCP District Medical Colleges TB Suspect Outdoor patient OPD DOTS Directory District/State/National Paper/Electronic Stay in Medical College DOTS Centre Drugs OPD OPD OPD OPD Diagnosed as TB Internal referral to DOTS Centre in Medical College / Referral Register Outside Feedback Referral Form in triplicate (pre-paid) 1 1 1 form with patient, 1 sent to DTO and 1 sent to TU
In-door patients Attending physician prescribes RNTCP regimen All indoor patients who reside in an RNTCP district, to be treated with RNTCP regimens using prolongation pouches. The DOTS Centre of the Medical College must be informed of the patient s admission as soon as possible. The patient will be registered under the local TU. The drug requirements to operationalise this system needs to be assessed by the respective DTOs and STOs, and CTD. Via the DOTS Centre in the Medical College On discharge, patient transferred to the DOTS centre nearest to the residence to continue and complete treatment
Monitoring Referral Register Referral for treatment form Feedback Monthly and Quarterly Reports
Referral Register SN Date on which the patient was referred Name of the patient Age Sex Address of patient 1 Date of smear examination, Lab Serial Number and results 2 P / EP Diagnosis Type of patient (N / R / F / TAD / O 3 ) CAT I / II / III Health facility to which patient has been referred Feedback 4
Form A Serial Number REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME Referral for Treatment Form (Fill in triplicate. Send one copy to the respective DTO receiving the patient [Form A], send one copy to the health facility where the patient is referred to [Form B], and give one copy to the patient [Form C]) Name and address of referring health facility Name of health facility to which patient is referred Name of patient Age Sex M F Complete Address Disease Classification Pulmonary Extra-pulmonary Site Category of Treatment Category I Category II Category III Type of Patient New Relapse Failure Treatment after default Other (specify) Sputum Status Date Month Year Result Laboratory number Name of Laboratory Relevant examination for Smear negative / Extra pulmonary cases Remarks Signature Date referred Designation - ----------------------------------------------------------------------------- --------------------------------------------------------------------------------- ---- Form A For use by the health facility where the patient has been referred Name of patient Age Sex M F Date of referral Serial Number Name of receiving health facility Name of TB Unit and District The above-named reported at this health facility on and has been put on treatment on Signature Designation Date (Send this part back to the referring unit as soon as the patient has reported and has been initiated on RNTCP treatment.)
Reporting system for Medical Colleges Central TB Division National Task Force Zonal quarterly report ( within 30 days) State quarterly report (within 20 days) Zonal Task Force State TB Cell State Task Force District TB centre Quarterly report (within 7 days) TB Unit Monthly PHI report (within 5 days) Medical College -1 Medical College -2
Medical College involvement in RNTCP number of med coleges number involved in RNTCP 276 262 286 273 307 282 321 291 343 315 2008 2009 2010 2011 2012 15
Trend of case notification from medical colleges 250000 200000 150000 100000 50000 0 2008 2009 2010 2011 2012 s+ diagnosed new smear positive TB-mc Total TB notified from Medcal colleges 16
Trend notification by type of cases new smear positive TB-mc new smear negative TB-mc extra pulmonary TB-mc 77966 79020 84015 81615 87271 83824 84697 82067 71531 46540 45666 49788 49031 45548 28287 2008 2009 2010 2011 2012 17
Proportion of TB cases notified by medical colleges over the years by type of cases 2008 2009 2010 2011 2012 35% 37% 35% 31% 21% 13% 13% 13% 14% 13% 14% 12% 14% 14% 7% Proportion from Med colleges-nsp Proportion from Med colleges-nsn Proportion from Med colleges-ep 18
Summary of contribution by different health sectors in 14 intensified urban PPM sites 2011 100% 90% 80% 70% 60% NGOs NGOs NGOs Pvt. Practitioners Pvt. Practitioners Pvt. Practitioners Medical College Other Govt. Medical College Other Govt. Medical College Other Govt. NGOs Pvt. Practitioners Medical College Other Govt. Corp. Sector NGOs 50% 40% 30% 20% State Govt. State Govt. State Govt. State Govt. Pvt. Practitioners Corp. Sector Medical College Other Govt. State Govt. 10% 0% Contribution to referral of chest symptomatics Contribution to all smear positive diagnosis Contribution to new smear positive case detection Contribution to DOT provision
Number of MDR TB Cases put on treatment Population covered under PMDT services (in millions) Population in Millions PMDT services-role of Medical Colleges 1400 1200 1000 800 600 400 200 4 4 5 7 8 9 13 13 18 18 18 19 19 20 27 29 31 34 37 38 42 45 47 ## Laboratories Certified under RNTCP Cumulative data up to March 2013 MDR TB Suspects Tested 182716 MDR TB case initiated on Rx 25727 XDR TB cases initiated on Rx 209 6000 5000 4000 3000 2000 1000 MDR TB Cases put on treatment 0 3Q-07 4Q-07 1Q-08 2Q-08 3Q-08 4Q-08 1Q-09 2Q-09 3Q-09 4Q-09 1Q-10 2Q-10 3Q-10 4Q-10 1Q-11 2Q-11 3Q-11 4Q-11 1Q-12 2Q-12 3Q-12 4Q-12 1Q-13 Quarter 0
PMDT and Medical Colleges Laboratory services PMDT sites (64/89) Generation of evidence 21
Success factors 22
Success factors 23
Success factors 24
Success factors 25
Challenges 26
Challenges 27
Challenges 28
Challenges 29
Opportunities 30
Opportunities 32
India PPM on the move National Strategic Plan 2012-17- Universal Access to TB Care- More thrust in PPM Establish PPM mechanisms National Technical working group (for guidance, policy advice) Technical support unit (for help to States for contracting) State PPM cell (internal or contracted) to help States contract and monitor intermediary agencies; guided by national level TSU. Private Provider Interface Agency (PPIA) to manage the many points of contact, monitor, move micro-payments for services
Approaches Accreditation/certification Innovative financing Diagnostics- labs Integrate with enhanced surveillance Schemes remain, but will be de-emphasized or phased out in favor of whatever works better
Private Public Interface Agency (PPIA) Improve case-finding, appropriate treatment and notification of cases Ensure notification of cases diagnosed & treated cases Ensure minimum quality standards as per the ISTC Provide or reimburse drugs for privately-treated patients for regimens Voucher/conditional cash transfer to patients (to use to purchase drugs that meet govt quality standards) And/or: social marketing of anti-tb drugs following agreed procedures and quality standards Design and deploy financing mechanisms to meet objectives